1. Personal Information

Transcription

1 small craft Proposal Form For crafts up to 5 metres (16 6 ) used for private pleasure purposes only

2 Please complete in BLOCK CAPITALS throughout and tick or in the appropriate boxes. 1. Personal Information Title (Mr, Mrs, Miss or other) Full Name I.D Card No or Passport No Date of Birth Postal Address Post Code Occupation including part-time Work (please be specific, Occupations such as Director, Clerk or Self-Employed are t sufficient) Home Telephone Number Office Telephone Number Mobile Number Address 2. Particulars of Hull Type of Craft Registration Number Name of Craft Year of Build Overall Length Material of Craft Was the craft professionally built or amateur built Builder s Name If amateur built or 15 years old or over, this proposal must be accompanied by a Full Condition Survey report. Conversions and crafts over 25 years old are t acceptable. Date of purchase Purchase Price Craft Make and Model

3 3. Particulars of Engine/s Make of Engine 1 and Serial Number HP Year of Manufacture State if Inboard or Outboard Make of Engine 2 and Serial Number HP Year of Manufacture State if Inboard or Outboard No cover is given on outboard motors until the Serial Number is advised. What is the maximum speed of the vessel with these engines? Kts / MPH 4. Values to be Insured Date Purchased Craft (including inboard if fitted and all electronic equipment) Purchase Price Value to be Insured* Engine 1 Engine 2 Road Trailer Life Jackets Total Sum Insured * Note: Value for insurance should be the current replacement cost of your craft taking into account your craft's age, condition, machinery, gear and equipment. 5. Moorings Where will the craft generally be moored when in commission? Where will the craft be laid up? Tick whether your craft will be kept: Ashore or Afloat State the dates between which the craft will be out of commission (laid-up) annually from to (inclusive)

4 6. General Questions 1. To the best of your kwledge and belief have you or any person you will permit to use the craft: (a) in possession of a valid nautical licence? (b) suffered any accident or loss in the last 5 years with any craft used or owned? (c) had any insurance on any craft cancelled or refused or had any special terms imposed? (d) ever been convicted or are currently being convicted of any criminal offence or contravention involving dishonesty? 2. Are you entitled to claim bonus? 3. Has the craft ever been damaged? 4. Will the craft be used for private purposes only? If the answer to any of these questions is YES please provide full details.

5 SUMMARY OF COVER PROVIDED - The Policy Cover 1.Loss or damage to the craft The craft is covered whilst in-commission anywhere within the Maltese Territorial Waters and whilst laid up at a location agreed with us. The policy provides cover for: Loss or damage to the craft and equipment caused by external accidental means including theft of craft. Theft of outboard motors and theft of trailers or the craft on them if fitted with an anti-theft device and immobilised or placed in locked premises. Transit by road within the Maltese islands, excluding scratching, denting or bruising. Loss or damage to outboard motors through dropping off or falling overboard. Emergency salvage charges necessary incurred in the safeguarding or recovery of the craft. 2. Liabilities The policy covers your legal liability arising from your interest in the craft for accidents happening on and about the craft up to an amount of 600,000 for any one incident including liability to and incurred by water-skiers towed by the craft. 3. Personal Accident The policy covers you and/or your immediate family for bodily injury or death whilst embarking, disembarking or whilst on board the craft up to a limit of 12,000 each including Medical Expenses up to 600 if you and/or immediate family are injured in an accident involving the craft. No Claims Bonus A No Claims Bonus rising up to 25% will be allowed on renewal of annual policies. Principal Exclusions Wear and tear, depreciation, deterioration or damage caused by vermin, insects or fungus. Loss or damage caused by war, strikes, riot and civil commotion. Latent defect, faulty design or construction. Any liability arising from accident whilst the craft is being moved or transported. Theft of trailers or any craft on them unless the trailers are fitted with an anti-theft device and are immobilised or placed in locked premises. Important The above description is a summary and must be regarded only as an outline. The policy is a legal document and as such defines the insurance cover in precise terms. A specimen may be inspected upon request. GMI/PCS/1115

6 Declaration Very Important You are reminded of the need to disclose any facts which the insurer would take into account in the assessment and acceptance of this proposal. If you have any doubts as to whether certain facts are relevant, ask your local GasanMamo Insurance Office. Failure to disclose all relevant facts may invalidate your policy or may result in your policy t operating fully. Please ensure that you keep a record (including copies of letters) of all information that you supply to us in relation to this proposal. Data Protection Notice To the extent that the information supplied by you, whether orally or in writing, constitutes personal data, including sensitive data within the provisions of the Data Protection Act, you consent to the processing of such data for purposes of administering your proposal for insurance, your Policy, underwriting, handling of claims and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. We may be required to collect further information from our sub-agents, other insurance companies, insurance intermediaries or insurance associations. In addition, we may pass some or all of the information to other insurance companies, or insurance associations for underwriting and claims handling purposes and also for the purposes of detecting, preventing and suppressing fraud and of keeping statistics. This also helps us to check the information provided. When we deal with your request for insurance, we may search this information. When you tell us about an incident which may or may t give rise to a claim, we will pass information relating to it to the Malta Insurance Association. We and other companies within our group would like, on occasion, to keep you informed of our products and services, by mail, fax, or other electronic means. Please inform us in writing if you do t wish to receive this information or if you wish to receive such information solely from GasanMamo Insurance Ltd. Moreover, we hereby ask you whether you wish to receive direct marketing information from us by to your address provided. You have the right to request access to, and rectification of, your personal data held by us by directing your request in writing signed by yourself to the Data Protection Officer, GasanMamo Insurance Ltd, Msida Road, Gzira GZR1405. Professional Secrecy Act Information on this form or on any subsequent claim form, along with other relevant information, may be shared with other Insurers as part of an exercise to combat the ever-increasing problem of insurance fraud. Signature of this Proposal Form confirms your consent to this fact-sharing exercise. Details shared are limited to what is absolutely necessary within the strict bounds of confidentiality and we will always regard your file as being a document protected by the Professional Secrecy Act, TOGETHER WE CAN FIGHT FRAUD I/We declare that the Information given in this proposal is to the best of my/our kwledge correct and complete in every detail. I/We confirm that I/we give consent, on the basis of the Data Protection Notice, on behalf of myself and any other persons specified in this form for the insurers to process our personal information with respect to this proposal and any subsequent claims. I/We also confirm that I/we have brought the Data Protection Notice to the attention of these persons. Further, I/we agree that if my answer has been written by any other person on my/our behalf, such person shall for that purpose be regarded as my/our Agent and t the Agent of GasanMamo Insurance. When completing this application, you should disclose any fact which may influence the acceptance of the risk. Signature Date Date of inception of Insurance No insurance will be in force until the proposal has been accepted by GasanMamo Insurance. For more information please contact: Address: Msida Road, Gżira GZR1405 Tel: Fax: insurance@gasanmamo.com gasanmamo.com